Short-Term Effects of Adding Topical Ketorolac to Intravitreal Bevacizumab in Diabetic Macular Edema: A Crossover Randomized Clinical Trial.

Purpose: To evaluate the short-term additive effects of topical ketorolac to intravitreal bevacizumab (IVB) in the management of center-involved diabetic macular edema (CI-DME). Methods: In a randomized double-masked placebo-controlled crossover clinical trial, eyes with CI-DME and the best-corrected visual acuity (BCVA) between (20/40) and (20/400) were included. These eyes should have had at least one intravitreal anti-VEGF injection in the preceding two months. They were randomized into two groups; while both groups received two IVB injections with a six-week interval, one group received topical ketorolac every 6 hr in the first interval and artificial tears every 6 hr as a placebo in the second interval and the other group received the same medications using a crossover method. The main outcome measures were changes in BCVA and central macular thickness (CMT). Results: Fifty-seven eyes of 35 patients with CI-DME were included in the study. The mean BCVA improvement was -0.09 ± 0.47 logMAR in the periods of receiving ketorolac and -0.03 ± 0.12 logMAR in the periods of placebo treatment, respectively (P = 0.99). Corresponding changes in CMT were -13.1 ± 170.1 and +11.7 ± 157.7 µm in the ketorolac and placebo periods, respectively (P = 0.322). The treatment effect was not statistically significant regarding both BCVA and CMT changes. Statistical analysis also disclosed that the carryover effect was insignificant for BCVA and CMT. Although the period effect was not significant for BCVA, it was at a meaningful level for CMT changes (P = 0.012). Conclusion: This crossover clinical trial demonstrated that in the course of DME treatment with IVB injections, topical ketorolac did not have any additive beneficial effect at least during a six-week period.

The effect of thyme essential oil and endothelial progenitor stem cells on lipopolysaccharide-induced sepsis in C57BL/6 mice.

Sepsis is a potentially fatal syndrome related to severe systemic inflammation developed by infection. Despite different antimicrobial therapies, morbidity and mortality rates remain high. Herbs along with cell therapy have been introduced as a promising option to improve the symptoms of sepsis. The present study aimed to evaluate the therapeutic effect of simultaneous administration of thyme essential oil (TEO) and endothelial progenitor stem cells (EPCs) on lipopolysaccharide (LPS)-induced sepsis in C57BL/6 mice. Sepsis was induced in C57Bl/6J mice by intraperitoneal injection of LPS, followed 2 h later by an intravenous injection of EPCs or oral administration of TEO or simultaneous administration of TEO and EPCs. After 10 days, the complete blood cell, renal and liver factors, serum levels of inflammatory cytokines, and angiogenic factors were measured. Simultaneous treatment with EPCs and TEO significantly increased the survival of mice with sepsis and modulated the inflammatory response by reducing the serum levels of pro-inflammatory cytokines. Moreover, this treatment significantly reduced the level of white blood cells and neutrophils and increased the number of red blood cells, the percentage of hematocrit, and hemoglobin. The combination of TEO with EPCs decreased organ injuries and was assessed by lower levels of the liver enzymes alanine aminotransferase and aspartate aminotransferase compared to the sepsis group. Administration of EPCs and TEO also significantly improved angiogenic factors, lung function, and toll-like receptor 4 expression. EPCs in combination with TEO increase survival in the LPS-induced sepsis mice model by acting on several targets. Thus, the combination of TEO with EPCs can be a feasible approach for the future clinical treatment and control of sepsis.

Assessing health determinants worldwide: Econometric analysis of the Global Burden of Diseases Study 2000-18 - Highlighting impactful factors on DALY, YLL, and YLD indicators.

Background: As the health status of a population is influenced by a variety of health determinants, we sought to assess their impact on health outcomes, both at the global and regional levels. Methods: This ecological study encompassed all 194 member countries of the World Health Organization (WHO) from 2000 to 2018. We first identified all health determinants and then retrieved the related data from various global databases. We additionally considered three indicators - disability-adjusted life years (DALYs), years of life lost (YLL), and years lived with disability (YLD) - in evaluating health outcomes; we extracted their data from the Global Burden of Disease (GBD) 2019 study. We then applied econometric analyses using a multilevel mixed-effects linear regression model. Results: The analysis using the DALY indicator showed that the variables of sexually transmitted infections, injuries prevalence, and urbanisation had the highest effect size or regression coefficients (ß) for health outcomes. The variables of sexually transmitted infection (ß = 0.75, P < 0.001) in the African region; drinking water (ß = -0.60, P < 0.001), alcohol use (ß = 0.20, P < 0.001), and drug use (ß = 0.05, P = 0.036) in the Americas region; urbanisation (ß = -0.34, P < 0.001) in the Eastern Mediterranean region; current health expenditure (ß = -0.21, P < 0.001) in the Europe region; injuries (ß = 0.65, P < 0.001), air pollution (ß = 0.29, P < 0.001), and obesity (ß = 0.92, P < 0.001) in the South-East Asia region; and gross domestic product (ß = -0.25, P < 0.001), education (ß = -0.90, P < 0.001), and smoking (ß = 0.28, P < 0.001) in the Western Pacific region had the most significant role in explaining global health outcomes. Except for the drug use variable in regional findings, the role of other variables in explaining the YLL indicator was greater than that of the YLD indicator. Conclusions: To address global health disparities and optimise resource allocation, global and interregional policymakers should focus on determinants that had the highest ß with health outcomes in each region compared to other regions. These determinants likely have a higher marginal health product, and investing in them is likely to be more cost-effective.

Uveal melanoma in the Iranian population: two decades of patient management in a tertiary eye center.

BACKGROUND: To assess the characteristics and outcomes of uveal melanoma management at a tertiary center in the Middle East. METHODS: A study on 164 patients with uveal melanoma was conducted by reviewing the available medical records, ultrasound, and pathology report results. Age at diagnosis, tumor location and size, treatment mode, visual outcome, metastasis, mortality, and survival were studied. RESULTS: The mean age of patients was 52.0 ± 15.0 years, and 52.5% were male. Choroidal melanoma was the most common uveal melanoma, followed by the ciliary body and iris melanoma. The mean thickness of tumors was 8.29 ± 3.29. The majority of patients (n = 111, 67.9%) were managed by brachytherapy with ruthenium-106 plaques. Enucleation was performed primarily in 46 (28%) patients and secondarily in nine (5.5%) patients. The sexual disparity was detected as the proximity of uveal melanoma to the fovea in males. For a 61-month mean follow-up period, mortality occurred in eight of our cases, six of which were due to metastasis. The most common site for distance metastasis was the liver (5/6), followed by the lung (1/6). The five-year and eight-year overall survival (OS) rate was 0.947%± 0.019. The 5-year survival rate reached zero in metastatic patients. OS was not statistically different depending on the age, tumor diameters, the primary treatment received, or the histopathologic findings (p > 0.50 for all). CONCLUSION: In this study, individuals diagnosed with UM exhibited an OS rate of around 94% at the five-year mark, which remained consistent up to eight years. Notably, the presence of distance metastasis emerged as the sole statistically significant factor influencing overall survival.

Non-COVID-19 hospitalization and mortality during the COVID-19 pandemic in Iran: a longitudinal assessment of 41 million people in 2019-2022.

BACKGROUND: During a COVID-19 pandemic, it is imperative to investigate the outcomes of all non-COVID-19 diseases. This study determines hospital admissions and mortality rates related to non-COVID-19 diseases during the COVID-19 pandemic among 41 million Iranians. METHOD: This nationwide retrospective study used data from the Iran Health Insurance Organization. From September 23, 2019, to Feb 19, 2022, there were four study periods: pre-pandemic (Sept 23-Feb 19, 2020), first peak (Mar 20-Apr 19, 2020), first year (Feb 20, 2020-Feb 18, 2021), and the second year (Feb 19, 2021-Feb 19, 2022) following the pandemic. Cause-specific hospital admission and in-hospital mortality are the main outcomes analyzed based on age and sex. Negative binomial regression was used to estimate the monthly adjusted Incidence Rate Ratio (IRR) to compare hospital admission rates in aggregated data. A logistic regression was used to estimate the monthly adjusted in-hospital mortality Odds Ratio (OR) for different pandemic periods. RESULTS: During the study there were 6,522,114 non-COVID-19 hospital admissions and 139,679 deaths. Prior to the COVID-19 outbreak, the standardized hospital admission rate per million person-month was 7115.19, which decreased to 2856.35 during the first peak (IRR 0.40, [0.25-0.64]). In-hospital mortality also increased from 20.20 to 31.99 (OR 2.05, [1.97-2.13]). All age and sex groups had decreased admission rates, except for females at productive ages. Two years after the COVID-19 outbreak, the non-COVID-19 hospital admission rate (IRR 1.25, [1.13-1.40]) and mortality rate (OR 1.05, [1.04-1.07]) increased compared to the rates before the pandemic. The respiratory disease admission rate decreased in the first (IRR 0.23, [0.17-0.31]) and second years (IRR 0.35, [0.26-0.47] compared to the rate before the pandemic. There was a significant reduction in hospitalizations for pneumonia (IRR 0.30, [0.21-0.42]), influenza (IRR 0.04, [0.03-0.06]) and COPD (IRR 0.39, [0.23-0.65]) during the second year. There was a significant and continuous rise in the hematological admission rate during the study, reaching 186.99 per million person-month in the second year, reflecting an IRR of 2.84 [2.42-3.33] compared to the pre-pandemic period. The mortality rates of mental disorders (OR 2.15, [1.65-2.78]) and musculoskeletal (OR 1.48, [1.20-1.82), nervous system (OR 1.42, [1.26-1.60]), metabolic (OR 1.99, [1.80-2.19]) and circulatory diseases (OR 1.35, [1.31-1.39]) increased in the second year compare to pre-pandemic. Myocardial infarction (OR 1.33, [1.19-1.49]), heart failure (OR 1.59, [1.35-1.87]) and stroke (OR 1.35, [1.24-1.47]) showed an increase in mortality rates without changes in hospitalization. CONCLUSIONS: In the era of COVID-19, the changes seem to have had a long-term effect on non-COVID-19 diseases. Countries should prepare for similar crises in the future to ensure medical services are not suspended.

Zero-Inflated Count Regression Models in Solving Challenges Posed by Outlier-Prone Data; an Application to Length of Hospital Stay.

Introduction: Ignoring outliers in data may lead to misleading results. Length of stay (LOS) is often considered a count variable with a high frequency of outliers. This study exemplifies the potential of robust methodologies in enhancing the accuracy and reliability of analyses conducted on skewed and outlier-prone count data of LOS. Methods: The application of Zero-Inflated Poisson (ZIP) and robust Zero-Inflated Poisson (RZIP) models in solving challenges posed by outlier LOS data were evaluated. The ZIP model incorporates two components, tackling excess zeros with a zero-inflation component and modeling positive counts with a Poisson component. The RZIP model introduces the Robust Expectation-Solution (RES) algorithm to enhance parameter estimation and address the impact of outliers on the model's performance. Results: Data from 254 intensive care unit patients were analyzed (62.2% male). Patients aged 65 or older accounted for 58.3% of the sample. Notably, 38.6% of patients exhibited zero LOS. The overall mean LOS was 5.89 (± 9.81) days, and 9.45% of cases displayed outliers. Our analysis using the RZIP model revealed significant predictors of LOS, including age, underlying comorbidities (p<0.001), and insurance status (p=0.013). Model comparison demonstrated the RZIP model's superiority over ZIP, as evidenced by lower Akaike information criteria (AIC) and Bayesians information criteria (BIC) values. Conclusions: The application of the RZIP model allowed us to uncover meaningful insights into the factors influencing LOS, paving the way for more informed decision-making in hospital management.

Efficacy of a self-monitoring traffic light diary on outcomes of patients with heart failure: A randomized controlled trial.

BACKGROUND AND OBJECTIVE: Patients with heart failure experience high hospitalization. However, patients cannot recognize symptoms according to current approaches, which needs to be improved by new self-monitoring instruments and strategies. Thus, we aimed to assess a self-monitoring traffic light diary on outcomes of patients with heart failure. METHODS: This was a single-blind, two-arm parallel group randomized controlled trial at the heart failure clinic of Tehran Heart Center (Tehran, Iran). Adult patients with a definitive diagnosis of heart failure with reduced ejection fraction (i.e., ejection fraction of less than 40 %), and New York Heart Association functional classes II-IV were included. A block-balanced randomization method was used to assign eligible subjects to the intervention or control group. Baseline data were collected before random allocation. Participants in the intervention group received a comprehensive intervention consisting of (1) self-care education by an Australian Heart Foundation booklet on heart failure, (2) regular self-monitoring of weight and shortness of breath at home, and (3) scheduled call follow-ups for three months. Patients in the control group received usual care. The primary outcome was heart failure self-care; the secondary outcomes were heart failure quality of life, knowledge, and all-cause hospitalization. RESULTS: From June to August 2017, 68 patients were included in the study. The overall age of participants was 55 (13.6) years old, and 71 % of patients were male. A significant association between the intervention and self-care maintenance (ß 5.1; 95 % CI 2.50 to 7.70, P < 0.001), self-care management (ß 10.6; 95 % CI 6.50 to 14.8, P < 0.001), self-care confidence (ß 8.0; 95 % CI 5.0 to 11.0, P < 0.001) and heart failure knowledge (ß 1.7; 95 % CI 1.30, 2.04; P < 0.001) was found. However, there was no association between the intervention and quality of life (ß 2.5; 95 % CI -0.79, 5.88, P 0.135) and hospitalization-free survival of the two groups (Log-Rank P 0.540). CONCLUSION: A self-monitoring traffic light diary can improve self-care behaviors and heart failure knowledge in patients with heart failure with reduced ejection fraction. RCT APPROVAL ID: Iranian Registry of Clinical Trials IRCT2017021032476N1. STUDY PROTOCOL: PMCID: PMC6262204.

Changes in emergency department visits and mortality during the COVID-19 pandemic: a retrospective analysis of 956 hospitals.

BACKGROUND: During the COVID-19 pandemic, many non-COVID-19 emergency department (ED) visits were indirectly affected. ED visits and mortality were assessed during different pandemic time periods compared with pre-pandemic. METHODS: The study used data from 41 million Iran Health Insurance Organization members. The outcomes were non-COVID-19 ED visits and associated mortality in 956 hospitals. An analysis of ED visits was conducted both for all-cause and cause-specific conditions: cardiovascular diseases (CVD), mental and substance use disorders, unintentional injuries, and self-harm. In addition, total in-hospital ED mortality was analyzed. A negative binomial regression and a Poisson regression with a log link were used to estimate the incidence rate ratio (IRR) of visits and mortality relative risk (RR). RESULTS: 1,789,831 ED visits and 12,377 deaths were reported during the study. Pre-pandemic (Sep 2019 to Feb 2020), there were 2,767 non-COVID-19 visits rate per million person-month, which decreased to 1,884 during the first COVID-19 wave with a national lockdown from Feb 20 to Apr 19, 2020 (IRR 0.68, [0.56-0.84]). The non-COVID-19 ED mortality risk was 8.17 per 1,000 visit-month during the pre-pandemic period, rising to 12.80 during the first wave of COVID-19 (RR 1.57, [1.49-165]). Non-COVID-19 ED visit rates decreased during the first pandemic year from Sep 2020 to Feb 2021 (IRR 0.73, [0.63-0.86]), but increased after COVID-19 vaccination two years later from Sep 2021 to Feb 2022 (IRR 1.11, [0.96-0.17]). The total ED mortality risk for non-COVID-19 was significantly higher after the COVID-19 outbreak in the first (RR 1.66, [1.59-1.72]) and second years (RR 1.27, [1.22-1.32]) of the pandemic. The visit incidence rate for mental health and substance use disorders declined from 8.18 per million person-month to 4.57 (IRR 0.53, [0.32 to 0.90]) in the first wave. In the second year, unintentional injury visits increased significantly compared with pre-pandemic (IRR 1.63, [1.30-2.03]). As compared to before the pandemic, there was no significant change in CVD and self-harm visit rates during the pandemic. Cardiac arrest was the leading cause of death in Iran hospitals' EDs. CONCLUSION: In the first year of the COVID-19 pandemic, non-COVID-19 hospital ED visits declined and mortality risk increased. Despite two years since the COVID-19 outbreak, non-COVID-19 ED mortality risk remains high.

Choosing the Best Instrument for Measuring Health Spillover Effect in Caregivers of Patients With Multiple Sclerosis.

OBJECTIVES: To measure the health spillover effect in caregivers of patients with multiple sclerosis (MS), we aimed to select the best instrument from 2 common health-related quality of life (QoL) instruments, the 3-level EQ-5D (EQ-5D-3L) and the Health Utilities Index Mark 3 (HUI-3), by assessing them. METHODS: Using consecutive sampling, 452 primary caregivers of patients with MS were asked to fill out a Care-related QoL instrument (CarerQol-7D), EQ-5D-3L, HUI-3, and the Center for Epidemiologic Studies Depression Scale between October 2019 and May 2020. Convergent and clinical validity were assessed to measure spillover effect in caregivers of patients with MS. RESULTS: A strong correlation of health-utility scores between EQ-5D-3L and HUI-3 (r = 0.914, P < .01) was observed. The 95% limit of agreement (LoA) for CarerQol-7D and HUI-3 (-10.6 to 8.2) was narrower than the LoA for CarerQol-7D and EQ-5D-3L (-15.1 to 17.1). Both EQ-5D-3L and HUI-3 proved clinical validity for the QoL of caregivers. The CarerQoL-7D score was significantly lower in female (P < .001), single (P < .014), lower-educated (P < .001), parent's relatives (P < .001), and unemployed (P < .001) caregivers. CONCLUSIONS: We found that both, EQ-5D-3L and HUI-3, were appropriate for measuring caregivers' QoL, although HUI-3 was a better choice because of its narrower LoA. Our findings suggest researchers should use HUI-3 to measure the quality-adjusted life-year of caregivers to aggregate with the QoL of patients in the denominator of an economic evaluation equation, such as the cost-effective ratio.

Prevalence of refractive errors in population aged 50 years and over: The Gilan eye study.

PURPOSE: To describe the prevalence of refractive error (RE) and its association with other environmental and health factors among population aged ≥50 years who lived in Gilan, Iran in 2014. METHODS: In this population-based cross-sectional study, 3281 individuals aged ≥50 years living in Gilan for at least 6 months were enrolled. The prevalence of different types of REs including myopia (spherical equivalent (SE)≤-0.50D), high myopia (SE ≤ -6.00D), hyperopia (SE≥ + 0.50D), high hyperopia (SE≥ + 3.00D), astigmatism (cylinder < -0.50D) and high astigmatism (cylinder < -2.25D) were determined. Anisometropia was defined as the SE difference of ≥1.00D between the two eyes. Associated factors including age, body mass index (BMI) and education were also studied. RESULTS: 2587 eligible individuals (58% female subjects) with the mean age of 62.6 ± 8.8 years participated (87.6% response rate). The prevalence of myopia, hyperopia and astigmatism was 19.2%, 48.6% and 57.4%, respectively. 3.6% high hyperopia, 0.5% high myopia and 4.5% high astigmatism were identified. The positive simultaneous effects3 of older age (Odds Ratio (OR) = 3.14), nuclear (OR = 1.71) and posterior subcapsular (OR = 1.61) cataracts as well as the negative effects of higher levels of education (OR = 0.28) were obtained on myopia. Higher BMI was found as a risk factor for hyperopia (OR = 1.67), while older patients were less likely to be hyperopic (OR = 0.31). CONCLUSION: Higher incidence of myopia and astigmatism was found in patients aged over 70 years. It was also found that patients at older ages who suffered with cataracts were at a higher risk of myopia, while elderly people with greater BMI were at a higher risk of hyperopia.

Effects of hydrolyzed collagen alone or in combination with fish oil on the gut microbiome in patients with major burns.

Burns are associated with gut dysbiosis. Collagen peptides and omega-3 fatty acids (FAs) are suggested to improve wound healing and the inflammatory response. These are also correlated with microbiome colonization. Therefore, the present study aimed to investigate the effect of hydrolyzed collagen alone or in combination with fish oil on specific species of the gut microbiome in patients with major burns. In this randomized double-blind clinical trial, 57 adults (aged 18-60 years) with 20-45% total body surface area burns were randomised into three groups to receive either 40 gr hydrolyzed collagen +10 ml sunflower oil, 40 g hydrolyzed collagen +10 ml fish oil or placebo, divided into two daily drinks, for two weeks. Gut bacteria were measured using the real-time quantitative polymerase chain reaction (qPCR) method. The mean concentration of Bifidobacterium was significantly reduced in the control (P = 0.002) and collagen (P = 0.005) groups compared with the baseline values, whereas no significant change was observed in the collagen omega-3 group. The Firmicutes to Bacteroidetes ratio decreased significantly in the collagen group (p = 0.002) after supplementation compared to baseline . No significant changes in concentration of Lactobacillus, Enterobacteriaceae, and F.prausnitzii were observed between or within the study groups. Two weeks of supplementation with collagen and omega-3 FAs in patients with major burns did not result in a significant difference in the concentration of bacteria measured between the study groups. However, the addition of omega-3 FAs prevented a significant reduction in gut Bifidobacterium. Future studies are suggested to investigate the potential efficacy of these nutrients in improving the gut microbiota and clinical outcomes in major burns. REGISTRATION NUMBER: IRCT20131125015536N9.

Implications of the Serum Concentrations of Neuregulin-4 (Nrg4) in Patients with Coronary Artery Disease: A Case-Control Study.

Background: Neuregulin-4 (Nrg4), a novel brown fat-enriched factor, has been reported to play a crucial role in developing metabolic disorders. The current case-control study aimed to investigate the association between serum Nrg4 and coronary artery disease (CAD). Methods: This study enrolled 43 patients with CAD and 43 subjects with normal coronary arteries diagnosed by coronary angiography. Anthropometric and biochemical parameters were measured and recorded. The serum Nrg4 level was determined using the enzyme-linked immunosorbent assay. The relationships between circulating Nrg4 and CAD and other clinical parameters were analyzed. A receiver operating characteristic analysis was applied to assess the utility of Nrg4 in identifying CAD. Results: The study population comprised 86 patients, including 64 men (74.4%), at a mean age of 57.83±6.01 years. Patients with CAD had significantly lower serum Nrg4 than the control group (P<0.001). The serum Nrg4 level was negatively correlated with anthropometric variables, including the body mass index, waist circumference, and the waist-to-hip ratio, fasting blood glucose, and the triglyceride-glucose index (P<0.05). In multivariable-adjusted regression analysis, the odds of CAD decreased by 46% per 1 SD elevation in the serum Nrg4 level (OR, 0.54; 95% CI, 0.40 to 0.73; P<0.001) after controlling for potential confounders. Nrg4 showed a significantly high area under the curve value (AUC, 0.85; 95% CI, 0.75 to 0.94) with 81.4% sensitivity and 95.3% specificity to identify CAD. Conclusion: Generally, the serum level of Nrg4 declines in patients with CAD, which might be an independent risk factor for CAD.

Effect of diet low in advanced glycation end products on appetite, body composition, and brown adipose tissue markers in patients with coronary artery disease treated with angioplasty: A randomized controlled trial.

Background: Recent changes in dietary habits have resulted in increased intake of advanced glycation end products (AGEs), which are known to have a predominant contribution to the pathogenesis and complications of coronary artery disease (CAD). AGEs are also thought to induce weight gain by affecting appetite, energy expenditure, and brown adipose tissue (BAT). Here, we investigated whether the restriction of dietary AGEs could affect appetite, body composition, anthropometric indices, and BAT-derived markers in CAD patients treated with angioplasty. Materials and Methods: Forty-two stented CAD patients were randomly allocated into two groups that received either a low-AGEs or a control diet for 12 weeks. At baseline and postintervention, fasting blood samples were analyzed for total AGEs, nesfatin-1, and BAT-derived markers (fibroblast growth factor 21 and neuregulin 4). Subjective appetite ratings and body composition were evaluated using the Visual Analog Scale (VAS) and bioelectric impedance analysis. Anthropometric indices, including fat mass index (FMI), abdominal volume index (AVI), and body adiposity index (BAI), were calculated through the relevant formula. Results: Restricting dietary AGEs for 12 weeks could cause a significant reduction in weight, FMI, AVI, and BAI (P < 0.05) compared to the comparison group. In addition, VAS data analyses indicated a significant decrease in the sense of hunger and prospective food intake (P < 0.05) in the intervention group compared to the comparison group. No significant difference was seen in the measured biochemical markers between the two groups. Conclusion: This study indicated that the low-AGEs diet could decrease appetite, weight, and anthropometric indices in stented CAD patients.

Sector area index: a novel supporting marker for blepharoptosis screening and grading.

PURPOSE: To introduce a new supporting marker for discriminating different grades of ptosis called Sector Area Index (SAI) and a semi-automated technique to calculate it. METHODS: In this cross-sectional comparative case series, a circle enclosing the intercanthal distance was automatically drawn after choosing two points as the medial and lateral canthus and manually selecting the palpebral fissure region. Finally, 15-degree apart sectors are applied to the enclosed circle. SAI was measured automatically by dividing the area of each 15-degree sector marked with the upper eyelid contour by the total area of the sector marked with the edge of the surrounding circle. SAI values and inter-eye SAI differences were compared between patients with different grades of ptosis as well as normal patients. RESULTS: In the current study, 106 eyes were recruited (30, 25, 27, and 24 in the control, mild, moderate, and severe ptosis groups, respectively). Mean values of SAI in all sectors showed a decreasing trend from normal individuals toward patients with severe ptosis. The mean difference values of SAI between study eyes and fellow eyes in all four groups of patients showed a statistically significant difference (p < 0.05). In a pairwise comparison between groups, mean values of SAI in all nasal sectors from 15° to 60° showed a statistically significant difference between all groups (p < 0.05). CONCLUSION: The mean difference of SAI between study eyes and fellow eyes, including eyelid curvature, especially in 15°-60° and 120°-165° sectors, can demonstrate differentiating performance for detecting and discriminating varying grades of ptosis.

A Stepped-Wedge Cluster-Randomized Controlled Trial of Multi-interventional Approach for Fall Prevention.

BACKGROUND AND OBJECTIVES: Falls are one of the most common adverse events at hospitals that may result in injury and even death. They are also associated with raised length of stay (LOS) and hospitalization costs. This experiment aimed to examine the effectiveness of multiple interventions in reducing inpatient fall rates and the consequent injuries. METHODS: The present study was a stepped-wedge cluster-randomized controlled trial. It was done in 18 units in a public university hospital over 36 weeks. Patients included in this research were at risk of falls. Overall, 33 856 patients were admitted, of whom 4766 were considered high-risk patients. During the intervention phases, a series of preventive and control measures were considered, namely staff training; patient education; placement of nursing call bells; adequate lighting; supervision of high-risk patients during transmission and handovers; mobility device allocation; placement of call bell and safe guard in bathrooms; placing "fall alert" signs above patients' beds; nurses informing physicians timely about complications such as delirium and hypoxia; encouraging appropriate use of eyeglasses, hearing aids and footwear; keeping side rails up; and reassessing patients after each fall. The primary outcome was participant falls per 1000 patient-days. Secondary outcomes were fall-related injuries and LOS. RESULTS: The results revealed a decrease in fall rate (n = 4 per 1000 patient-days vs 1.34 per 1000 patient-days, incidence rate ratio (IRR) = 0.19 [95% confidence interval (CI), 0.14-0.26]; P = .001) and injuries (n = 2.4 per 1000 patient-days vs 0.79 per 1000 patient-days, IRR = 0.22 [95% CI, 0.15-0.32]; P = .001) in exposed compared with unexposed phases. There was not a significant difference in LOS (exposed mean 10.63 days [95% CI, 10.26-10.97], unexposed mean 10.84 days [95% CI, 10.59-11.09], mean difference = -0.13 [95% CI, -0.53 to 0.27], P = .52). CONCLUSIONS: This multi-interventional trial showed a reduction in falls and fall rates with injury but without an overall effect on LOS. Further research is needed to understand the sustainability of multiple fall prevention strategies in hospitals and their long-term impacts.

Validity of the models predicting 10-year risk of cardiovascular diseases in Asia: A systematic review and prediction model meta-analysis.

We aimed to review the validity of existing prediction models for cardiovascular diseases (CVDs) in Asia. In this systematic review and meta-analysis, we included studies that validated prediction models for CVD risk in the general population in Asia. Various databases, including PubMed, Web of Science conference proceedings citation index, Scopus, Global Index Medicus of the World Health Organization (WHO), and Open Access Thesis and Dissertations (OATD), were searched up to November 2022. Additional studies were identified through reference lists and related reviews. The risk of bias was assessed using the PROBAST prediction model risk of bias assessment tool. Meta-analyses were performed using the random effects model, focusing on the C-statistic as a discrimination index and the observed-to-expected ratio (OE) as a calibration index. Out of 1315 initial records, 16 studies were included, with 21 external validations of six models in Asia. The validated models consisted of Framingham models, pooled cohort equations (PCEs), SCORE, Globorisk, and WHO models, combined with the results of the first four models. The pooled C-statistic for men ranged from 0.72 (95% CI 0.70 to 0.75; PCEs) to 0.76 (95% CI 0.74 to 0.78; Framingham general CVD). In women, it varied from 0.74 (95% CI 0.22 to 0.97; SCORE) to 0.79 (95% CI 0.74 to 0.83; Framingham general CVD). The pooled OE ratio for men ranged from 0.21 (95% CI 0.018 to 2.49; Framingham CHD) to 1.11 (95%CI 0.65 to 1.89; PCEs). In women, it varied from 0.28 (95%CI 0.33 to 2.33; Framingham CHD) to 1.81 (95% CI 0.90 to 3.64; PCEs). The Framingham, PCEs, and SCORE models exhibited acceptable discrimination but poor calibration in predicting the 10-year risk of CVDs in Asia. Recalibration and updates are necessary before implementing these models in the region.

Covariates of a healthy diet and physical activity self-management one year after Bariatric surgery: A cross-sectional study.

BACKGROUND: Healthy diet and physical activity self-management is important in maintaining weight loss and preventing weight regain after bariatric surgery. We aimed at evaluating covariates of healthy diet and physical activity self-management among patients undergone bariatric surgery using Health Action Process Approach (HAPA) model. METHOD: In this cross-sectional study, 272 patients with a history of bariatric surgery were selected from the data registry of Tehran Obesity Treatment Study (TOTS). Data were collected using bariatric surgery self-management standard questionnaire (BSSQ), and items based on HAPA model for healthy diet and physical activity self-management. Data were analyzed using Path analysis and AMOS version 24. RESULTS: The mean score of self-management was (32 ± 10SD). Coping planning construct (ß = 0.22; p<0.001) and risk perception (ß = 0.02; p<0.01) in dietary self-management and action planning (ß = 0.16; p = 0.001) and risk perception (ß = 0.001; p = 0.17) in physical activity self-management had the highest and lowest effect powers, respectively. Coping planning (ß = 0.22; p<0.001) and action planning (ß = 0.17; p<0.03) in diet, and action planning (ß = 0.16; p = 0.010) in physical activity were significantly related to self-management. Also, task-coping self-efficacy (ß = 0.28; and p<0.001), outcome expectancies (ß = 0.37; p<0.001), risk perception (ß = 0.13; p = 0.015) in diet and coping self-efficacy (ß = 0.50; p<0.001), outcome expectancies (ß = 0.12; p = 0.021) in physical activity were significantly related to behavioral intention. The values of CFI = 0.939 and RMSEA = 0.052 for diet and CFI = 0.948 and RMSEA = 0.048 for physical activity indicated adequate fit. CONCLUSION: HAPA was applicable as a framework for interventions promoting healthy diet and physical activity self-management in patients who have undergone bariatric surgery.

Larvicidal Effects of Metabolites Extracted from Nocardia and Streptomyces Species against the Forth Larval Stage of Anopheles stephensi (Diptera: Culicidae).

Background: Larvicidal agents can be produced using microbial resources, which are environmentally friendly, biodegradable, and economical. The study's goal was to evaluate the larvicidal activity of metabolites isolated from Nocardia (N. fluminea, N. soli and N. pseudobrasiliensis) and Streptomyces (S. alboflavus) bacterial species against Anopheles stephensi. Methods: Four metabolites isolated from Nocardia and Streptomyces strains were exanimated for larvicidal activity. The experiments were performed for 24, 48, and 72 hours. 300, 350, 400, 450, 500, 550, and 600 µl of Actinobacteria metabolites were added to 100 cc of dechlorinated water. Fourth-stage larvae were placed in dechlorinated water as a control. LC50 and LC90 were calculated using toxicity data and analyzed. Results: All metabolites had a statistically significant influence on mosquito larvae (P< 0.05). At 24, 48, and 72 hours, the LC50 for N2 (N. fluminea) was 417, 386, and 370 ppm, respectively, and the LC90 was 650, 595, and 561 ppm. Moreover, LC50 for N4 (N. soli) was 389, 376, and 347 and LC90 were 591, 565, and 533 and LC50 for N5 (N. pseudobrasiliensis) was 390, 357, and 341 ppm and LC90 were 589, 532 ppm. In addition, LC50 for S921 (S. alboflavus) was 484, 416, and 382 ppm, and LC90 was 701, 612, and 574 ppm. Conclusion: The four bacterial metabolites tested in our study were found to have a notable effect on the mortality rate of Anopheles stephensi larvae, indicating their potential as natural larvicides. This is an effective technique for controlling Anopheles stephensi that has no detrimental environmental impact.

Prevalence of cataract and its contributing factors in Iranian elderly population: the Gilan eye study.

PURPOSE: To report the prevalence and the associated factors leading to cataract among the Iranian population living in Gilan Province, Iran. METHODS: This population-based cross-sectional study was performed from June to November 2014 on 2,975 residents aged ≥ 50 years old living in urban and rural regions of the Gilan Province in Iran. A representative sample of residents in the province was recruited into the study through door-to-door visiting, and baseline data were collected by questionnaire. All participants were referred to the medical center for comprehensive ophthalmic examination, laboratory tests, and blood pressure measurement. RESULTS: Among the population, 2,588 (86.99%) subjects were eligible to be included in this study, categorized either into the cataract or the non-cataract group. The mean age of participants was 62.59 ± 8.92 years, and 57.5% were female. Higher prevalence of cataract was found in individuals of older ages (odds ratio (OR) = 1.13; 95% confidence interval (CI) = 1.10 to 1.16; P < 0.001) and a history of previous ocular surgery (OR = 5.78; 95% CI = 2.28 to 14.63; P < 0.001). At the same time, a lower prevalence of cataract was seen in patients exposed to sunlight for more than 4 h per day (OR = 0.49; 95% CI = 0.32 to 0.73; P = 0.001). CONCLUSION: Cataract affects 50.50% of the study population, especially those over 80. The mildest form of cataract, grade zero, is the most common. Surgery for cataract has good outcomes. The risk of cataract is higher for those older or who have had eye surgeries. People not affected by cataract tend to be exposed to more sunlight.

The relationship of circulating neuregulin 4 and irisin, and traditional and novel cardiometabolic risk factors with the risk and severity of coronary artery disease.

BACKGROUND AND AIMS: Neuregulin 4 (NRG4) and irisin are adipokines that have been suggested to be associated with cardiometabolic risk factors and coronary artery disease (CAD), but the data are inconclusive. This study aimed to investigate the relationship between circulating NRG4 and irisin and cardiometabolic risk factors with CAD risk and severity. METHODS AND RESULTS: In this cross-sectional study, the presence of CAD and the severity of stenosis (gensini score) were documented based on coronary angiography in 166 adults. Circulating NRG4 and irisin, glucose homeostasis markers, hs-CRP, lipid profiles, blood pressure, and anthropometric measurements were assessed as well. Age (p = 0.005), sex (p = 0.008), SBP (p = 0.033), DBP (p = 0.04), MAP (p = 0.018), FBG (p = 0.012), insulin (p = 0.039) and HOMA-IR (p = 0.01) were significantly associated with odds of having CAD. The final logistic regression model showed that age, sex, HOMA-IR, and MAP were the most important determinants of having CAD. There were no significant associations between circulating irisin and NRG4 with odds of having CAD. The final general linear model showed that being men (ß = 17.303, 95% CI: 7.086-27.52, P = 0.001), age (Aß = 0.712, 95% CI: 0.21-1.214, P = 0.006), HOMA-IR (Aß = 2.168, 95% CI: 0.256 to 4.079, P = 0.027), and NRG4 level (ß = 1.836, 95% CI: 0.119-3.553, P = 0.036) were directly associated with higher gensini score. Participants with the three-vessel disease had a mean increase of about 5 units in circulating irisin compared to those with no clinical CAD (ß = 5.221, 95% CI: 0.454-9.987, p = 0.032). CONCLUSIONS: This study showed that the adipokines NRG4 and Irisin might be associated with the severity of coronary stenosis.